Surveillance for Avian Influenza among Humans and Animals

1
Surveillance for Avian Influenza among Humans and
Animals
2
Learning Objectives

• Understand current surveillance for avian
  influenza in poultry, wild birds, and humans
• Understand enhanced human surveillance in
  response to a highly pathogenic avian influenza
  outbreak in poultry or wild birds

3
Presentation Overview

• Federal Agencies
• Human Influenza Surveillance
• Routine
• Enhanced
• Animal Influenza Surveillance
• Poultry
• Wild Birds

4
Federal Agencies

• US Department of Health and Human Services (DHHS)
• CDC
• US Department of Agriculture (USDA)
• US Department of the Interior (DOI)

5
HHS

• Lead agency for avian influenza in humans
• Tasks
• Pandemic influenza planning
• Human surveillance
• Rapid response to HPAI in humans

6
USDA

• Lead agency for avian influenza in poultry
• Tasks
• International assistance
• Import restrictions
• Surveillance among domestic poultry
• Rapid response to HPAI
• Coordinates with states and industry

7
DOI

• Collaborating agency for avian influenza in wild
  birds
• Tasks
• Surveillance among wild migratory birds
• Protects health of employees and visitors on more
  than 500 million acres of federal lands
• Rapid response to HPAI in wild migratory birds
• Collaborates with USDA

8
Influenza Surveillance Among Humans
9
Routine National Surveillance

• Virologic - laboratory reporting
• Sentinel Providers Network
• State and territorial epidemiologists reports
• Emerging Infections Program
• New Vaccine Surveillance Network
• 122 Cities Mortality Reporting System
• Influenza-associated pediatric mortality

10
Routine State-Level Surveillance

• Monitor sentinel provider network data
• Monitor laboratory data
• Conduct mortality surveillance
• Provide state-level assessments based on
  state-specific surveillance
• Passive reporting of outbreaks in long-term care
  facilities and schools

11
Routine Local-Level Surveillance

• Monitor local data from sentinel providers
• Investigate and report influenza-related
  pediatric mortality
• Investigate clusters of influenza-like illness
  (ILI) that are
• a) outside of regular flu season, or
• b) in nursing homes or healthcare facilities
• Area-specific activities

12
Local Surveillance During Pandemic Alert

• Continue routine surveillance activities AND
• Investigate clusters of influenza-like illness
  with a) recent travel to area with documented
  novel or avian flu, or b) severe morbidity and
  mortality
• Facilitate viral testing for persons with ILI and
  epidemiologic risk factors

13
CDC Guidance for the Current Situation Enhanced
Surveillance

• Testing for avian influenza A (H5N1) virus
  infection is recommended for
• A patient who has an illness that
• Requires hospitalization or is fatal AND
• Has or had a documented temperature of 38C
  (100.4 F) AND
• Has radiographically confirmed pneumonia, acute
  respiratory distress syndrome (ARDS), or other
  severe respiratory illness for which an alternate
  diagnosis has not been established AND
• Has at least one of a list of potential exposures
  within 10 days of symptom onset

14
CDC Guidance Exposures

• Exposures to investigate if within 10 days of
  illness onset
• History of travel to a country with influenza
  H5N1 documented in poultry, wild birds, and/or
  humans, AND had at least one potential exposure
  (i.e. sick poultry) during travel
• Close contact (approach within 3 feet) of an ill
  patient who was confirmed or suspected to have
  H5N1
• Worked with live influenza H5N1 virus in a
  laboratory

15
Enhancing Local Surveillance

• Enhance surveillance and record review in
  hospitals
• Public Service Announcements
• Telephone hotlines
• Door-to-door surveys
• Occupational surveillance

16
Goals of Human Surveillance for Pandemic Influenza

• Virologic Surveillance
• Detect initial cases of pandemic strain
• Track introduction of virus to local areas
• Monitor changes in virus
• Disease-based Surveillance
• Early warning of increased ILI
• Monitor health effects of pandemic
• Track trends in disease activity

17
Human Surveillance

• Upon confirmed HPAI in animal species
• Conduct active case finding
• Assess exposures
• Classify and test potential cases

18
1. Active Case (and Contact) Finding

• Everyone with known or possible exposure 72 hours
  before bird symptoms
• Known or possible exposures
• Infected poultry
• Under- or uncooked infected poultry
• Infected wild or pet birds
• Manure and litter
• Contaminated surfaces, vehicles, equipment, etc
• Contaminated air space
• Within 3 ft of infected person

19
2. Exposure Assessment

• Characterize exposures
• Define target population
• Most likely to be exposed
• Those involved in HPAI control and eradication
• Poultry farm owners or employees, state and
  federal animal health agency employees

20
3. Classify and Test

• Classify the persons with severe or fatal
  respiratory disease as
• Suspect Case
• Confirmed Case
• Report Under Investigation
• Not a Case
• Perform laboratory testing

21
Interim Case Definition (H5N1)

• Suspect Case
• Must meet all of the following criteria
• Temperature of 100.4F or higher
• Cough, sore throat, or respiratory distress
• Exposure within 10 days of symptom onset
• Laboratory test pending, inadequate, or
  unavailable

22
Interim Case Definition (H5N1)

• Confirmed Case
• Meets clinical and exposure criteria for a
  Suspect Case, but laboratory testing is
  inconclusive
• - AND -
• Positive lab test for H5N1 by one of four methods

23
Interim Case Definition (H5N1)

• Report Under Investigation
• Exposure or clinical information is not available
• Additional information is necessary to classify

24
Poultry Outbreak and Human Surveillance Activities

• Limit case definition
• Disseminate case definition
• Health Alert Network (HAN)
• Epi-X
• Create and disseminate outbreak reporting
  questionnaire
• Consider database and reporting tools
• Identify and interview potential cases and
  contacts

25
Surveillance Activities cont.

• Conduct surveillance for human illness linked to
  affected premises
• Ensure timely reporting of cases to CDC
• Characterize seasonal influenza strains
• Notify other states that might receive cases or
  contacts
• Advise contacts to monitor symptoms for 10 days
  post-exposure

26
Contacts

• Definition
• Asymptomatic individuals who have potentially
  been exposed as defined by the exposure criteria
  in the suspect case definition.

27
Possible Contacts

• Poultry workers
• Agriculture responders
• Farmers
• Veterinarians
• People purchasing poultry products
• Farm visitors
• Travelers

28
Possible Contacts

• Also
• Healthcare workers
• Family members and other close contacts
• Emergency Medical Services staff

29
Recommendations for Contacts

• Self-monitor for symptoms for 10 days after last
  exposure
• Evaluate for antiviral prophylaxis
• Receive seasonal flu vaccine
• Adhere to infection control procedures
• If symptoms develop, reclassify according to case
  definitions

30
Influenza Surveillance Among Animals
31
Animal Surveillance

• Poultry
• Live bird markets
• Commercial flocks
• Backyard flocks
• Other Birds
• Imported birds
• Wild birds
• Pet birds

32
Notifiable AvianInfluenza (NAI)
Avian influenza in its notifiable form (NAI) is
defined as an infection of poultry caused by any
influenza A virus of the H5 or H7 subtypes or by
any AI virus with an intravenous pathogenicity
index (IVPI) greater than 1.2 (or as an
alternative at least 75 mortality) as described
NAI viruses can be divided into highly pathogenic
notifiable avian influenza (HPNAI) and low
pathogenicity notifiable avian influenza (LPNAI)

Protecting American Agriculture
33
Markets

• Licensing
• Bird testing and recordkeeping
• Sanitation and biosecurity
• Surveillance
• Response

Protecting American Agriculture
34
Live Bird Markets

• Prevent and control LPAI
• Markets
• Production facilities
• Distributors
• Regular monitoring and surveillance of all
  facilities in volunteer states
• Quarterly random testing
• Quarterly closure with depopulation, cleaning,
  disinfection and down time
• State-level monitoring in non-participating states

35
Commercial Flocks

• National Poultry Improvement Plan (NIPP)
• USDA program
• Monitor poultry production facilities
• Random testing of flocks
• Test all ill birds
• Coordinate with states for response and
  containment plans

36
Surveillance NPIP

On- farm

• Establishes standards for evaluation of poultry
  breeding stock and hatchery products
• Avian influenza free certification for
  commercial companies

Protecting American Agriculture
37
Surveillance NPIP (cont.)

• New LPAI program that will provide for H5 and H7
  AI monitoring and indemnity for LPAI.
• Program components
• AI monitored program
• Surveillance specifications
• State LPAI response and containment plans

Protecting American Agriculture
38
Domestic, Non-Commercial

• Backyard Flocks
• Biosecurity for the Birds program
• Report sick birds to an animal health
  professional
• Practice biosecurity
• Collaborators
• State Departments of Agriculture
• USDA Cooperative Extension Service
• Private veterinarians

39
Imported Birds

• USDA mandates quarantine and testing all imported
  birds for avian influenza
• Poultry
• Pet birds
• Zoo birds
• Ratites (i.e. ostriches and emus)
• Current ban on live or fresh birds or poultry
  from areas where the Asian strain H5N1 virus
  exists

40
Wildlife Surveillance

• Five components to surveillance
• Investigation of morbidity and mortality
• Surveillance in live wild birds
• Surveillance in hunter-killed birds
• Sentinel species monitoring
• Environmental sampling

41
Wild Bird Surveillance The USG Interagency
Strategic Plan

• Part of the Presidents National Strategy for
  Pandemic Influenza
• Partnership among
• U.S. Departments of Agriculture, Interior, Health
  and Human Services
• Association of Fish and Wildlife Agencies
• National Association of Public Health
  Veterinarians
• State agencies
• Unified national system for early detection of
  highly pathogenic H5N1 AI in wild birds. Provides
  standard procedures and strategies for sampling,
  diagnostics and data management.
• Serves as a guide for regional and state
  surveillance plans.

Protecting American Agriculture
42
Migratory Birds

• Capture, sample, test
• Monitor and test wild birds
• Alaska / Pacific flyway
• Mississippi (Central) flyway
• Atlantic flyway
• Collaborators DOI, USDA, USGS, US Fish and
  Wildlife, state agencies, and others

43
Case Definition for Poultry

• Surveillance at the flock level, rather than
  individual level (as in human surveillance)
• Clinical case definition of HPAI in poultry
  flocks
• Symptoms of illness such as drops in egg
  production, lack of energy and appetite, nasal
  discharge, lack of coordination, swollen head and
  legs
• AND/OR
• Unusual mortality

44
Diagnostic Testing in Poultry

• Rapid screening test RRT-PCR
• Identifies H5 or H7 viruses
• Available within 4-7 hours
• Confirmation by National Veterinary Services
  Laboratory (NVSL)
• Confirmatory testing viral isolation
• Genetic sequencing
• Pathogenicity test
• Available within 5-10 days of receipt

45
LPAI Surveillance National Animal Health
Laboratory Network (NAHLN)

Labs

• More than 45 laboratories participate in the
  network. NAHLN labs
• Provide laboratory services nationwide
• Provide laboratory data for reporting
• Respond to foreign animal disease outbreaks
• Focus on animal diseases

Protecting American Agriculture
46
Presumptive Positive in Poultry

• Sudden and significant increase in mortality
• With clinical signs - or -
• Post mortem lesions - and -
• Decrease in egg production
• Positive RRT-PCR for H5 or H7
• From NVSL, NAHLN, or other USDA-approved lab

47
Reporting HPAI in Poultry

• Reporting varies by state
• Industry
• Backyard flocks
• H5 or H7 LPAI
• Presumptive positive cases reported to USDA or
  DOI will be immediately reported to
• OIE (World Organization for Animal Health)
• Trade partners
• Other Federal agencies
• States
• Industry

48
Response in the Event of an HPAI Outbreak
Outbreak

• Response actions for domestic flocks
• Surveillance
• Quarantine and humane euthanasia
• Cleaning and disinfection of premises
• Possible use of vaccine in poultry
• Indemnity payments
• Communication to media and the public

Protecting American Agriculture
49
Responding to Influenza among Poultry

• Response begins with presumptive positive or
  positive result on HPAI screening test
• Coordination between USDA, DOI, HHS, states,
  industry, tribes
• National HPAI Response Plan goals
• Prevent contact between virus and susceptible
  animals
• Stop virus production in infected animals
• Increase disease resistance of susceptible
  animals through strategic vaccination

50
Responding to Influenza among Poultry

• LPAI outbreak
• Affected state takes the lead
• Clean, disinfect, depopulate affected premises
• USDA provides funding
• Close attention to H5 and H7 strains
• HPAI outbreak
• USDA takes the lead
• Quarantine, clean, disinfect, and cull the
  infected and exposed bird population
• CDC is notified
• Bird owners compensated

51
Surveillance after HPAI Outbreak in Poultry

• Implemented within 48 hours of index case
  identification
• Major goals
• Define extent of outbreak
• Detect new cases to facilitate rapid control
  measures
• Monitoring of flocks and wild birds on suspect
  and at-risk premises

52
Summary

• Avian influenza surveillance among animals and
  humans involves collaboration among many local,
  state, and federal agencies
• Surveillance among humans occurs routinely, and
  would be enhanced under an increased threat of
  pandemic influenza
• Surveillance among animals involves domestic,
  wild, and imported birds

53
References

• USDA National HPAI Response Plan, Aug 2006,
  http//www.aphis.usda.gov/newsroom/hot_issues/avia
  n_influenza/contents/printable_version/DraftSummar
  yNationalHPAIresponseplan08-31-06.pdf
• An early detection system for highly pathogenic
  H5N1 avian influenza in wild migratory birds,
  U.S. Interagency Strategic Plan, March 2006,
  http//www.doi.gov/issues/birdflu_strategicplan.pd
  f
• Morgan, A. Avian influenza an agricultural
  perspective. J Infect Diseases. 2006194(Suppl
  2)S139-S146

54
References

• USDAS Role in the Implementation Plan for the
  National Strategy for Pandemic Influenza, May 6,
  2006. http//www.usda.gov/documents/AI_Fact_Sheet_
  Implementation_Plan.pdf
• USDA Avian Flu Brochure http//www.usda.gov/docume
  nts/AvianFluBrochure.pdf
• US Department of the Interior, Issues of
  Interest Avian Influenza (Bird Flu).
  http//www.doi.gov/issues/avianflu.html
• WHO Case Definitions http//www.who.int/csr/disea
  se/avian_influenza/guidelines/case_definition2006_
  08_29/en/print.html